89R15058 SCL-D     By: González of El Paso H.B. No. 4046       A BILL TO BE ENTITLED   AN ACT   relating to an enrollee's cost-sharing liability for emergency care   under a health benefit plan.          BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS:          SECTION 1.  Subtitle A, Title 8, Insurance Code, is amended   by adding Chapter 1224 to read as follows:   CHAPTER 1224.  COST-SHARING LIABILITY   SUBCHAPTER A.  GENERAL PROVISIONS          Sec. 1224.001.  DEFINITIONS. In this chapter:                (1)  "Cost-sharing liability" means the amount an   enrollee is responsible for paying for a covered health care   service or supply under the terms of a health benefit plan.  The   term includes deductibles, coinsurance, and copayments but does not   include premiums, balance billing amounts by out-of-network   providers, or the cost of health care services or supplies that are   not covered under a health benefit plan.                (2)  "Emergency care" has the meaning assigned by   Section 1301.155.                (3)  "Enrollee" means an individual, including a   dependent, entitled to coverage under a health benefit plan.                (4)  "Health care provider" means a practitioner,   institutional provider, or other person or organization that   furnishes health care services and that is licensed or otherwise   authorized to practice in this state.  The term includes a   pharmacist and a pharmacy.          Sec. 1224.002.  APPLICABILITY OF CHAPTER.  This chapter   applies only to a health benefit plan that provides benefits for   medical or surgical expenses incurred as a result of a health   condition, accident, or sickness, including an individual, group,   blanket, or franchise insurance policy or insurance agreement, a   group hospital service contract, or an individual or group evidence   of coverage or similar coverage document that is issued by:                (1)  an insurance company;                (2)  a group hospital service corporation operating   under Chapter 842;                (3)  a health maintenance organization operating under   Chapter 843;                (4)  an approved nonprofit health corporation that   holds a certificate of authority under Chapter 844;                (5)  a multiple employer welfare arrangement that holds   a certificate of authority under Chapter 846;                (6)  a stipulated premium company operating under   Chapter 884;                (7)  a fraternal benefit society operating under   Chapter 885;                (8)  a Lloyd's plan operating under Chapter 941; or                (9)  an exchange operating under Chapter 942.          Sec. 1224.003.  EXCEPTION. This chapter does not apply to   the state Medicaid program, including the Medicaid managed care   program operated under Chapter 540, Government Code.          Sec. 1224.004.  RULES. The commissioner may adopt rules to   implement this chapter.   SUBCHAPTER B.  REGULATION OF COST-SHARING LIABILITY FOR EMERGENCY   CARE          Sec. 1224.051.  ISSUER REQUIREMENTS. Notwithstanding any   other law, a health benefit plan issuer:                (1)  shall pay a health care provider the full amount   payable to the provider under the terms of the enrollee's health   benefit plan, including the enrollee's cost-sharing liability, for   covered emergency care;                (2)  has the sole responsibility for collecting the   amount due for an enrollee's cost-sharing liability under the   enrollee's health benefit plan for emergency care; and                (3)  on an enrollee's request, shall collect the amount   due for the enrollee's cost-sharing liability for emergency care   throughout the plan year in increments determined by the issuer.          Sec. 1224.052.  ISSUER PROHIBITIONS. A health benefit plan   issuer may not:                (1)  withhold any amount for an enrollee's cost-sharing   liability from a payment to a health care provider for covered   emergency care;                (2)  require a health care provider to offer additional   discounts for emergency care to enrollees outside the terms of a   contract between the issuer and the provider;                (3)  cancel an enrollee's health benefit plan for   failure to collect amounts due under the enrollee's cost-sharing   liability for emergency care; or                (4)  use additional expenses incurred by complying with   this chapter as a basis for increasing an enrollee's premiums or   decreasing payments to a health care provider.          Sec. 1224.053.  ENFORCEMENT OF SUBCHAPTER. (a)  A violation   of this chapter is an unfair method of competition or an unfair or   deceptive act or practice in the business of insurance under   Chapter 541 and is subject to enforcement under that chapter.          (b)  Notwithstanding Section 541.002, a health benefit plan   issuer is considered a person for purposes of enforcing this   subchapter under Chapter 541.          SECTION 2.  Section 1271.008(a), Insurance Code, as   effective September 1, 2025, is amended to read as follows:          (a)  A health maintenance organization shall provide written   notice in accordance with this section in an explanation of   benefits provided to the enrollee and the physician or provider in   connection with a health care service or supply provided by a   non-network physician or provider.  The notice must include:                (1)  a statement of the billing prohibition under   Section 1271.155, 1271.157, or 1271.158, as applicable;                (2)  a statement of:                      (A)  with respect to emergency care subject to   Section 1271.155, the total amount payable to the physician or   provider under the enrollee's health benefit plan, the total amount   the physician or provider may bill the enrollee, if applicable, the   total amount of the enrollee's cost-sharing liability owed to the   health maintenance organization, and an itemization of copayments,   coinsurance, deductibles, and other amounts included in that   cost-sharing liability; and                      (B)  with respect to a health care service or   supply subject to Section 1271.157 or 1271.158, the total amount   the physician or provider may bill the enrollee under the   enrollee's health benefit plan and an itemization of copayments,   coinsurance, deductibles, and other amounts included in that total;   and                (3)  for an explanation of benefits provided to the   physician or provider, information required by commissioner rule   advising the physician or provider of the availability of mediation   or arbitration, as applicable, under Chapter 1467.          SECTION 3.  Section 1271.155(g), Insurance Code, is amended   to read as follows:          (g)  For emergency care subject to this section or a supply   related to that care, [a non-network physician or provider or a   person asserting a claim as an agent or assignee of the physician or   provider may not bill] an enrollee [in, and the enrollee] does not   have financial responsibility for[,] an amount greater than an   applicable copayment, coinsurance, and deductible under the   enrollee's health care plan that:                (1)  is based on:                      (A)  the amount initially determined payable by   the health maintenance organization; or                      (B)  if applicable, a modified amount as   determined under the health maintenance organization's internal   appeal process; and                (2)  is not based on any additional amount determined   to be owed to the physician or provider under Chapter 1467.          SECTION 4.  Section 1301.0053(b), Insurance Code, is amended   to read as follows:          (b)  For emergency care or post-emergency stabilization care   subject to this section or a supply related to that care, [an   out-of-network provider or a person asserting a claim as an agent or   assignee of the provider may not bill] an insured [in, and the   insured] does not have financial responsibility for[,] an amount   greater than an applicable copayment, coinsurance, and deductible   under the insured's exclusive provider benefit plan that:                (1)  is based on:                      (A)  the amount initially determined payable by   the insurer; or                      (B)  if applicable, a modified amount as   determined under the insurer's internal appeal process; and                (2)  is not based on any additional amount determined   to be owed to the provider under Chapter 1467.          SECTION 5.  Section 1301.010(a), Insurance Code, as   effective September 1, 2025, is amended to read as follows:          (a)  An insurer shall provide written notice in accordance   with this section in an explanation of benefits provided to the   insured and the physician or health care provider in connection   with a medical care or health care service or supply provided by an   out-of-network provider.  The notice must include:                (1)  a statement of the billing prohibition under   Section 1301.0053, 1301.155, 1301.164, or 1301.165, as applicable;                (2)  a statement of:                      (A)  with respect to emergency care subject to   Section 1301.0053 or 1301.155, the total amount payable to the   physician or provider under the insured's preferred provider   benefit plan, the total amount the physician or provider may bill   the insured, if applicable, the total amount of the insured's   cost-sharing liability owed to the insurer, and an itemization of   copayments, coinsurance, deductibles, and other amounts included   in that cost-sharing liability; and                      (B)  with respect to a health care service or   supply subject to Section 1301.164 or 1301.165, the total amount   the physician or provider may bill the insured under the insured's   preferred provider benefit plan and an itemization of copayments,   coinsurance, deductibles, and other amounts included in that total;   and                (3)  for an explanation of benefits provided to the   physician or provider, information required by commissioner rule   advising the physician or provider of the availability of mediation   or arbitration, as applicable, under Chapter 1467.          SECTION 6.  Section 1301.155(d), Insurance Code, is amended   to read as follows:          (d)  For emergency care subject to this section or a supply   related to that care, [an out-of-network provider or a person   asserting a claim as an agent or assignee of the provider may not   bill] an insured [in, and the insured] does not have financial   responsibility for[,] an amount greater than an applicable   copayment, coinsurance, and deductible under the insured's   preferred provider benefit plan that:                (1)  is based on:                      (A)  the amount initially determined payable by   the insurer; or                      (B)  if applicable, a modified amount as   determined under the insurer's internal appeal process; and                (2)  is not based on any additional amount determined   to be owed to the provider under Chapter 1467.          SECTION 7.  The changes in law made by this Act apply only to   a health benefit plan delivered, issued for delivery, or renewed on   or after January 1, 2026.  A health benefit plan delivered, issued   for delivery, or renewed before January 1, 2026, is governed by the   law as it existed immediately before the effective date of this Act,   and that law is continued in effect for that purpose.          SECTION 8.  This Act takes effect September 1, 2025.